Abstract
BackgroundUnhealthy alcohol use involves a spectrum from hazardous use (exceeding guidelines but no harms) through to alcohol dependence. Evidence-based management of unhealthy alcohol use in primary health care has been recommended since 1979. However, sustained and systematic implementation has proven challenging. The Continuing Quality Improvement (CQI) process is designed to enable services to detect barriers, then devise and implement changes, resulting in service improvements.MethodsWe conducted a systematic review of literature reporting on strategies to improve implementation of screening and interventions for unhealthy alcohol use in primary care (MEDLINE EMBASE, PsycINFO, CINAHL, the Australian Indigenous Health InfoNet). Additional inclusion criteria were: (1) pragmatic setting; (2) reporting original data; (3) quantitative outcomes related to provision of service or change in practice. We investigate the extent to which the three essential elements of CQI are being used (data-guided activities, considering local conditions; iterative development). We compare characteristics of programs that include these three elements with those that do not. We describe the types, organizational levels (e.g. health service, practice, clinician), duration of strategies, and their outcomes.ResultsFifty-six papers representing 45 projects were included. Of these, 24 papers were randomized controlled trials, 12 controlled studies and 20 before/after and other designs. Most reported on strategies for improving implementation of screening and brief intervention. Only six addressed relapse prevention pharmacotherapies. Only five reported on patient outcomes and none showed significant improvement. The three essential CQI elements were clearly identifiable in 12 reports. More studies with three essential CQI elements had implementation and follow-up durations above the median; utilised multifaceted designs; targeted both practice and health system levels; improved screening and brief intervention than studies without the CQI elements.ConclusionUtilizing CQI methods in implementation research would appear to be well-suited to drive improvements in service delivery for unhealthy alcohol use. However, the body of literature describing such studies is still small. More well-designed research, including hybrid studies of both implementation and patient outcomes, will be needed to draw clearer conclusions on the optimal approach for implementing screening and treatment for unhealthy alcohol use. (PROSPERO registration ID: CRD42018110475).
Highlights
Unhealthy alcohol use involves a spectrum from hazardous use through to alcohol dependence
Programs oriented towards multiple-organizational levels, as well as studies longer than 12 months were associated with significant effects on improvement of implementation of screening and/or brief intervention compared to single strategy programs [7, 8]
Search strategy To construct the search strategy, we first conducted a broad text-word search in MEDLINE. From this search (14,764 results) we identified a set of representative reports that met the inclusion criteria by systematically screening 20% of the search results for abstracts that met the inclusion criteria
Summary
Unhealthy alcohol use involves a spectrum from hazardous use (exceeding guidelines but no harms) through to alcohol dependence. Evidence-based management of unhealthy alcohol use in primary health care has been recommended since 1979. Evidencebased management of unhealthy alcohol use in primary health care (PHC), the use of screening and brief intervention (SBI), has been advocated since the World Health Organization (WHO) called for the development of strategies and guidelines for SBI applicable in PHC settings [2,3,4,5]. There is little evidence of significant effects of implementation strategies on patients’ alcohol consumption [8] Barriers, such as time pressures, staff retention, lack of training and leadership, as well as the clinicians’ perception of alcohol discussions as sensitive, have been identified [6, 11, 13]. To improve detection and treatment of unhealthy alcohol use, more work is needed to develop and test approaches that are sensitive to facilitators and barriers in an individual PHC setting
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